Doctors urged to treat obesity as a disease under new guidelines

by American Heart Association News

This is the second in a five-part series that explains what the new heart disease and stroke prevention guidelines mean to you.

Doctors should consider obesity a disease and more actively treat obese patients for weight loss, according to new guidelines released by the American Heart Association, American College of Cardiology and The Obesity Society.

The guidelines are essentially an instruction manual for treatment. New strategies in the guidelines released in early November include prescribing patients a diet that cuts out 500 or more calories a day and an exercise plan that gets patients moving at least 2 ½ hours each week. Also, included is behavioral counseling to help patients stick with the plan.

Physicians also should consider weight-loss surgery for severely obese patients who have one or more obesity-related health problem, such as diabetes, sleep apnea or high blood pressure. In the past, doctors waited until patients were struggling with two such issues.

At the heart of the changes to the guidelines is the concept that obesity is now considered a disease and that doctors should work more closely with obese patients. In June, the American Medical Association also officially recognized obesity as a disease.

“Telling patients they need to lose weight is not enough. We want healthcare providers to own the problem. Just like they own the problem of glycemic control in a patient with diabetes, they need to own the problem of weight management,” said Donna Ryan, M.D., co-chair of the committee that wrote the guidelines and professor emeritus at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge.

The guidelines were released on Nov. 12 and reflect the latest information that scientists have about weight loss to prevent heart disease and stroke, the nation’s No. 1 and No. 4 killers.

It has been 15 years since federal health officials released guidelines for managing obesity. Since then, obesity has become considered a nationwide epidemic. One in three U.S. adults is obese, increasing their risk for high blood pressure, Type 2 diabetes, heart disease and stroke. The disease costs $190 billion a year in weight-related medical bills. Another third of Americans are overweight.

“The subsequent health problems of obesity and the risk factors passed down through generations have become increasingly more of a burden. That’s the siren sound we can no longer ignore,” said Gordon Tomaselli, M.D., past president of the American Heart Association and co-chair of the subcommittee that guided the completion of the guidelines. Tomaselli is chief of cardiology at Johns Hopkins University School of Medicine in Baltimore.

More people benefit from weight loss than previously thought

Anchoring the new guidelines is a first-of-its-kind roadmap to help patients lose weight and keep it off. It starts with finding out who needs to lose weight by calculating at least once a year every American’s body mass index, which helps estimate the appropriateness of overweight or obesity, based on height and weight. The American Heart Association offers an online BMI calculator for adults.

Patients with a BMI of 30 or higher are considered obese and need treatment. For instance, that would include a 5-foot-5 woman who weighs more than 180 pounds or a 5-foot-10 man who weighs at least 209 pounds.

The new guideline also recommends weight loss for some overweight people. Someone would qualify with a BMI of 25 to 29.9, and one risk factor, such as elevated blood pressure or high triglycerides (blood fats). That’s a change from the 1998 federal guidelines that said overweight people needed to have at least two risk factors to benefit from weight loss.

The next step is for patients to participate in a medically supervised weight loss program two or three times a month for at least six months. The formula for weight loss combines three parts: eat fewer calories than your body needs, get aerobic exercise for 30 minutes most days of the week and learn the skills to change unhealthy behaviors.

Behavioral strategies may include monitoring weight, setting goals, tracking food and calorie intake and creating an environment at home and work that discourages overeating. Counseling also helps people shore up their ability to deal with temptations and other challenges to their weight-loss plan.

Patients are more likely to follow a weight loss routine when guided by a registered dietitian, behavioral psychologist or other trained professional in a healthcare setting, according to the guidelines. Telephone- and web-based weight loss programs also work, though not as well.

‘There is no magic diet for weight loss’

The new guidelines finally put to rest the idea that there is an ideal weight loss diet for everyone, Ryan said, adding, “There is no magic diet for weight loss.”

In fact, she said, more than a dozen dietary patterns have proven effective in helping people lose weight as long as they involve eating fewer calories than the body needs to maintain weight. Some diets call for higher protein. Others are built on eating fewer carbohydrates or reduced fat.

Providers should use a person’s food preferences and health to select the most appropriate diet. For example, someone with high cholesterol might benefit most from a low-fat diet that reduces both weight and cholesterol.

People also don’t need to reach a normal weight to reap the health benefits of weight loss. Shedding even a modest number of pounds can have significant health benefits, said Frank Hu, M.D., Ph.D., an American Heart Association volunteer who helped write the guidelines.

“Sustained weight loss of just five percent can significantly lower blood pressure, blood glucose and improve blood lipids,” said Hu, a professor of nutrition and epidemiology at Harvard School of Public Health in Boston.

For a 180-pound woman, that’s a weight loss of just nine pounds. Even as little as 3 percent weight loss can lower the risk for Type 2 diabetes, the guidelines say.

For people trying to keep the weight off, exercise is more essential. The guidelines recommend 200 to 300 minutes of physical activity a week to prevent extra pounds from creeping back. People should also participate in a weight loss maintenance program for at least one year. “You really need a full year to engrain those healthy behaviors around food and exercise,” Ryan said.

Although the guidelines did not compare commercial weight loss programs, the recommendations should be incorporated into those plans to help participants succeed.
The guidelines also did not look at obesity medications since the two currently available weight loss drugs only recently entered the market. Future updates will include recommendations for weight loss drugs as more research becomes available, Ryan said.

Weight loss surgery recommended for certain patients

For extremely obese people whose health is at high risk, surgery may be needed if behavioral approaches have not worked.

Bariatric surgery should be an option for people with a BMI of 40 or higher and people with a BMI of 35 or higher who have at least one obesity-related health problem, such as Type 2 diabetes or sleep apnea, the guidelines say. Previous guidelines required patients to have at least two health problems.

The guidelines do not endorse any one weight loss surgery. Rather, the choice of procedure should be based on the person’s age, severity of obesity, the risk of complications and other factors. In the U.S., about 200,000 adults have bariatric surgery each year.

The guidelines do not recommend weight loss surgery for people with a BMI under 35. “These procedures have a tremendous impact on Type 2 diabetes control and lowering the risk of death. But even though a lot of diabetes surgeons want the BMI cutoff lowered to 30, we still don’t have the evidence to support that,” Ryan said.

More health insurers starting to cover obesity screening and counseling

Few healthcare providers currently offer medically supervised weight loss programs, Ryan said. But she hopes that by providing supportive scientific evidence, patients will start telling their doctors they want it, doctors will begin providing it and health insurers will start covering it.

Under the Affordable Care Act, Medicare and most private insurance plans include obesity screening and counseling for adults with a BMI of 30 or higher, and diet counseling for any adult with high cholesterol or other risk factor for cardiovascular disease. Starting in 2014, all new plans sold through the health insurance marketplace must also provide free coverage for these and other preventive services.

Private plans vary widely in the type of weight counseling they provide and for how long. Some plans may cover the cost of commercial weight loss programs, while others may pay for gym memberships or telephone counseling.

Medicare beneficiaries can receive face-to-face behavioral counseling for six months, with a primary care doctor, certified clinical nurse specialist, nurse practitioner or physician’s assistant providing the counseling. Medicare covers counseling for an additional six months in patients who lose at least 6.6 pounds in the first six months.

For people who would benefit from expensive bariatric surgery, coverage is not required as part of the new healthcare law, though insurance companies are increasingly covering weight loss surgery for people who qualify. Medicare covers bariatric surgery for eligible patients. Patients should contact their insurance company to check their coverage.

For overweight people who would benefit from weight loss based on the new guideline, some healthcare flexible spending accounts allow people to use pre-tax dollars for weight loss counseling or programs.

The most important message of the guideline, Ryan said, is that weight loss is not just about willpower. “It’s about behaviors around food and physical activity, and getting the help you need to change those behaviors.”

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